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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803049
Report Date: 07/31/2024
Date Signed: 07/31/2024 05:37:29 PM

Document Has Been Signed on 07/31/2024 05:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VARENNA AT FOUNTAINGROVEFACILITY NUMBER:
496803049
ADMINISTRATOR/
DIRECTOR:		BUOT, FERDINANDFACILITY TYPE:
741
ADDRESS:1401 FOUNTAINGROVE PKWYTELEPHONE:
(801) 815-0808
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 322CENSUS: DATE:
07/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Ferdinand Buot-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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Licensing Program Analysts (LPAs), Alviso and Loera, conducted an annual inspection, on 7/31/24 at approximately 1:10pm, and met with Administrator/Executive Director Ferdinand Buot.

The fire clearance is approved for Villetta building(1st & 2nd FL)-132 non-ambulatory, includes 8 bedridden, third floor of Villeta building 72 ambulatory only, Casitas #1 through #27, 54 non-ambulatory, and North & South buildings, 64 non-ambulatory. LPA checked random fire extinguishers which were serviced and tagged as required.

Per file review, an evacuation drill was held on 6/26/24; Various emergency drills, and fire drills are being conducted as required.

LPAs reviewed six (6) resident files; Files were complete. LPAs reviewed six (6) staff files. Staff had criminal record clearance as required. Staff had required annual training.

There are no deficiencies cited during today's inspection.
Exit interview conducted with the Administrator Ferdinand Buot.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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